Form INIRP-G State Form 48125 (R2 / 2-11) State of Indiana International Registration Plan SCHEDULE G FEIN/SSN: Staggered Month: IRP Account: Legal Name: Fleet: 1. Have you ever registered this vehicle or any other vehicles in Indiana? Yes No Yes 2. If yes please attach a copy of the previous registration(s), list under what name they were registered and the last date of registration: ______________________________________________________________________________________ 3. If you have not been IRP registered in Indiana, have you been IRP registered in any other state? (Please attach previous registrations) If you are estimating mileage for a first time or for expanded operations you must complete this form to justify your estimates. In accordance with the IRP agreement, your estimates will not be used if they do not appear to be reasonable. An estimated mileage chart is available for your use if you do not have an exact plan of operation of travel per state. The estimated mileage chart is determined by actual operations of other carriers registered in Indiana. Example of how to complete your trips below if you plan to use your own plan of operation: State: Kentucky List routes of travel: State: List routes of travel: State: List routes of travel: State: List routes of travel: State: List routes of travel: State: List routes of travel: State: List routes of travel: Under penalties of perjury, I declare that I have examined this form, including accompanying schedules and statements, and to the best of my knowledge and belief, it is true, correct, and complete. ________________________________________________________ Signature of Applicant ____________________________ Date American LegalNet, Inc. www.FormsWorkFlow.com No Mileage: 245 X X No. of Trips: 3 X X Vehicles: 2 = = Total Estimated Mileage 1,470 Louisville, KY to Clarksville, IN Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage Mileage: X X No. of Trips: X X Vehicles: = = Total Estimated Mileage